To fix or not to fix? The role of fibular fixation in distal shaft fractures of the leg.

BACKGROUND: The role of stabilisation of the fibula in distal two-bone fractures of the leg is controversial. Some studies indicate the need for fibular stabilisation in 43 AO fractures, but few studies consider the role of the fibula in 42 AO fractures. The aim of the current paper is to explain the role of stabilisation of the fibula in 42 AO fractures, correlating the rates of healing and non-union between patients with and without fibula fixation. MATERIALS AND METHODS: A total of 60 patients with 42 AO (distal) shaft fracture of the tibia with associated fracture of the fibula were selected. Patients were divided into two groups according to whether or not the fibula was fixed: Group I (n=26) comprised patients who had their fibula fixed while Group II (n=34) comprised patients who did not. The fibular fracture was classified according to the AO and related to the level of the tibial fracture. Other parameters examined were the union rate of the two groups correlated to the fracture pattern and position of the fibular fracture; the demographic data, such as age and gender; the presence of an open fracture, and the type of tibial fixation device used (nail or plate). RESULTS: None of the parameters considered (open injury, AO classification, device used and level of the fibular fracture relative to the tibial) were shown to have an influence on the development of a non-union. CONCLUSION: This study showed a higher non-union rate when the fracture of the tibia and fibula were at the same level, the tibia was fixed with a bridging plate and the fibula left untouched. For this reason, we recommend fibular fixation in all 42 distal fractures when both fractures lie on the same plane and the tibial fracture is relatively stabilised.

Slipped Upper Femoral Epiphysis (SUFE): to do or not to do in sufe.

Slipped upper femoral epiphysis (SUFE) is not an uncommon hip disease in adolescence. Usually, diagnosis of SUFE is delayed, has high risk of sequela and poor long-term results. This paper reviews the literature with a focus on epidemiology, aetiology, diagnosis, treatment and results regarding SUFE.

D.D.S.H.: developmental dysplasia of the spastic hip: strategies of management in cerebral palsy. A new suggestive algorithm.

Hip problems in cerebral palsy are relatively frequent (25-75%). Subluxation and dislocation of the hip is proportional to the neuromuscular involvement and is often due to alteration caused by spastic muscle forces acting on the femoral head in the acetabular cavity. The EMMA approach (Early Multilevel Minimally-invasive Approach) has been designed to restore muscle balance, decrease hip migration and prevent bone deformities thereby avoiding future pain with minimal biological cost to the patient. EMMA is suitable for most patients, especially those with increased tone, poor muscle control and selectivity, Reimer Index (R.I.) 20%. We consider age and R.I crucial prerequisites for treatment steps. EMMA 1) age 2-4 years, RI 20%: multilevel injection of botulinum toxin in case of muscular hyperactivity without morphological alterations of the couple muscle-tendon (contractures). EMMA 2) age 4-6, RI 20%: multilevel aponeurectomies in case of muscular hyperactivity with morphological alterations of the couple muscle-tendon (retraction). EMMA 3) early bone surgery (growth plates). This approach has been adopted in the last 4 years to prevent bone deformities and give early mobilisation and early control of the pain. EMMA is simple to apply even in infants, both for hip containment and to decrease spasticity.

Effects of aging and cyclosporin a on collagen turnover in human gingiva.

BACKGROUND: WE AIMED AT CHARACTERIZING THE AGING GINGIVA ANALYZING: i) collagen content and turnover in human gingival tissues and fibroblasts obtained from healthy young and aging subjects. ii) the effect of cyclosporin A administration in human cultured gingival fibroblasts obtained from aging compared to young subjects. METHODS: Morphological analysis was performed on haematoxylin-eosin and Sirius red stained paraffin-embedded gingival biopsies from young and aging healthy subjects. The expression of the main genes and proteins involved in collagen turnover were determined by real time PCR, dot blot and SDS-zymography on cultured young and aging gingival fibroblasts, and after cyclosporin A administration. RESULTS: Our results suggest that in healthy aged people, gingival connective tissue is characterized by a similar collagen content and turnover. Collagen turnover pathways are similarly affected by cyclosporin A treatment in young and aging gingival fibroblasts. CONCLUSIONS: Cyclosporin A administration affects gingival collagen turnover pathways in young and aging fibroblasts at the same extent, suggesting that during aging cyclosporin A administration is not related to relevant collagen turnover modifications.

Ultrasound evaluation of the hips and histological correlations in Ellis van Creveld Syndrome.

Ellis van Creveld Syndrome (EVCs) is a chondroectodermal dysplasia. Its clinical picture includes a meso-acromielic limb dwarfism with normal spine, involvement of the teeth, hair and nails, polydactyly of the hands and feet and heart malformations. Ultrasonography compared with histology were used in the present study to evaluate neo-natal ultrasonographic hip development and acetabular hysto-morphology in EVCs. A flat and abnormal acetabulum with small beta angles and non measurable alfa angles were detected at repeated ultrasonographic evaluations at birth and at four months, with irregular echoes spiking from the inner part of the sockets; the acetabular cavities contained large early ossified proximal femoral epiphyses. Histology was obtained from phal-angeal growth plates of a surgically removed extradigit, stained with alcian blue/PAS and E.E.. The growth plates showed a distorted anatomy with irregular column formation and abnormal distribution of the hypetrophic cells. Ultrasound morphology corresponded to the altered growth plates seen at histology. Early detection of an abnormally early developed proximal femoral ossification centre could be considered a diagnostic feature of the syndrome especially when present in the prenatal period. (Hip International 2004; 14: 39-43).

Microanatomy of the acetabular cavity and its relation to growth.

The anatomy and development of the growing acetabulum are not clearly understood. We dissected and studied histologically two acetabula from the pelvis of a three-month-old infant. Relative rates of growth at the different growth plates were assessed by comparing the height of the proliferative layer with that of the hypertrophic layer. The three bones which form the acetabulum are surrounded by growth plates on all sides except medially. These face towards the centre of the triradiate cartilage, the limbs of the triradiate cartilage and the articular surface and each may be divided into four distinct areas according to the orientation of its cell columns which reflect the direction of growth. Growth was particularly rapid at the ischial growth plates directed towards the centre and the articular cartilage, add on both sides of the anterior limb of the triradiate cartilage. These findings may explain the mechanism by which the acetabulum changes orientation and inclination with growth.

Bilateral hip surgery in severe cerebral palsy a preliminary review.

When cerebral palsy involves the entire body pelvic asymmetry indicates that both hips are 'at risk'. We carried out a six-year retrospective clinical, radiological and functional study of 30 children (60 hips) with severe cerebral palsy involving the entire body to evaluate whether bilateral simultaneous combined soft-tissue and bony surgery of the hip could affect the range of movement, achieve hip symmetry as judged by the windsweep index, improve the radiological indices of hip containment, relieve pain, and improve handling and function. The early results at a median follow-up of three years showed improvements in abduction and adduction of the hips in flexion, fixed flexion contracture, radiological containment of the hip using both Reimer's migration percentage and the centre-edge angle of Wiberg, and in relief of pain. Ease of patient handling improved and the satisfaction of the carer with the results was high. There was no difference in outcome between the dystonic and hypertonic groups.

Acetabular notch.

Ultrasound images of dysplastic and/or unstable hips often display an indentation or notch at the superolateral part of the acetabulum where the iliac wing joins the acetabular roof. We reviewed the ultrasound and subsequent radiographic examinations of 295 babies examined in our hip screening clinic. Of the hips with a notch demonstrable at the first ultrasound, 97% had a persistent notch at the second ultrasound and in 79% the notch was apparent on the 3-month radiograph. When the notch persists, we believe that it represents damage to the lateral acetabular ring epiphysis and delayed maturation of the lateral acetabulum.

Errors in measurement of acetabular index.

Errors in determining the acetabular index can be induced either by incorrectly positioning the child for radiographs or by inter- or intraobserver errors. From postmortem radiographic studies, we have determined the magnitude of these errors. The error caused by pelvic rotation is +/- 3 degrees if the obturator foramina ratio is kept within 0.5 to 2. If pelvic flexion/extension is confined to +/- 10 degrees, the error induced by flexion/extension is +/- 3 degrees. The intraobserver error was +/- 2 degrees, and the interobserver error was +/- 3 degrees. Under these circumstances, the total error is +/- 5 degrees. We have not been able to find a satisfactory way of limiting the flexion/extension to +/- 10 degrees. In some circumstances, particularly if a child is distressed, the flexion/extension may be 20 degrees from neutral; under these circumstances, errors as large as 10 degrees can occur. Surgeons should be aware that very large errors can occur when the acetabular index is measured.

[Persistent coxalgia in the child. The value of magnetic resonance]. / Coxalgia persistente del bambino. Apporto della risonanza magnetica.

This study was aimed at assessing the Magnetic Resonance (MR) features of persistent hip pain in children. Twenty-six patients aged 1.6 to 15.2 years (mean: 6.5 years) were clinically selected for the study; at clinics, all patients had persistent hip pain after 10 days' therapy. All patients were examined with radiography, US and MRI at 0.5 T. SE T1-weighted sequences, with and without fat suppression (FS), SE T2-weighted and gradient echo (GE) T1-weighted-like (T1*) sequences were acquired on the coronal plane. Slices were 5 and 3 mm thick on SE and GE T1* sequences, respectively. Morphology and signal intensity of epiphysis, growth plate and metaphysis were prospectively studied with MRI. Clinical and/or imaging follow-up (3 months) was the reference standard in our study. Final diagnoses were: no evidence of alteration (n = 3), transient synovitis (n = 6), rheumatic fever (n = 3), Perthes' disease (n = 7), Meyer's dysplasia (dysplasia epiphysealis capitis femoris, DECF) (n = 2), early slipped capital femoral epiphysis (n = 2), incomplete fracture (n = 1), extraarticular cause of pain (muscular abscess, osteomyelitis) (n = 2). In 23 of 26 patients MRI confirmed clinical, radiographic and US findings. MRI was particularly helpful in making an unquestionable diagnosis in the other 3 cases; in a patient with suspected slipped capital femoral epiphysis MRI revealed an incomplete fracture, in a patient with suspected Meyer's dysplasia MRI revealed early Perthes' disease and finally in a patient with suspected transient synovitis MRI revealed Perthes' disease. To conclude, MRI allows the condition causing persistent hip pain to be assessed and accurately depicted, integrating clinical, radiographic and US findings and in some cases also changing diagnosis and therapy.

The acetabular notch in hip dysplasia.

In the first few months of life, a notch may be seen on radiographs of the superolateral margin of the infant hip. It may be associated with a steeply inclined acetabular roof and may be an indicator of persistent neonatal instability or displacement of the femoral head.

Red cell aging and active calcium transport.

The authors have investigated the relationships between the active calcium transport across the human red blood cell (RBC) membrane and the RBC aging processes in vivo and in vitro. For the study of this biological system, the authors have determined the active calcium uptake by inside-out membrane vesicles obtained from selected RBC populations. This model provided an optimal way to assess the biochemical and functional responses of the human cell to the oxidative stimulus triggered by the cellular aging processes. The activity of the calcium pump is indeed strictly correlated to the oxidative damage suffered by the RBC, being higher in the aged RBC. It appears that the main controller of the active calcium transport is the age-dependent protein inhibitor of the calcium pump.

The effect of in vitro and in vivo cellular aging on the active calcium transport in human inside-out red cell membrane vesicles.

Modelling of the in vivo and in vitro aging processes in the human red cell has stressed the following features of the active calcium uptake by inside-out vesicles: 1) it is higher in the outdated, in vitro aged, than in the fresh red cell (p less than 0.0005), and in the densest, in vivo aged fraction than in the lightest, young fraction (p = 0.08); 2) it increases following stimulation by excess calmodulin to values that are not significantly different; 3) it decreases to the same value in the absence of endogenous calmodulin and inhibitor, with and without exogenous calmodulin; 4) it is the target of a non-competitive inhibition, that is stronger in the fresh than in the outdated red cell. We conclude that the aging process does not involve neither membrane Ca-ATPase nor calmodulin, but rather the interaction of the calcium pump with the inhibitor of Ca-ATPase.